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WEDNESDAY, April 25, 2018 (HealthDay News) -- As the United States grapples with an ongoing opioid epidemic, experts are calling attention to a hidden aspect of the crisis: Many overdose deaths may, in fact, be suicides.
The researchers describe suicide as a "silent contributor" to the nation's opioid overdose death rate.
It's hard to know exactly how many Americans have intentionally overdosed on opioids in recent years, said report author Dr. Maria Oquendo, a professor of psychiatry at the University of Pennsylvania. The analysis of the issue is published April 26 in the New England Journal of Medicine.
One problem, she explained, is that there are different ways of establishing a "manner" of death across the country. "Manner" refers not to the cause -- a drug overdose, for example -- but whether a death was a homicide, suicide or accident.
Unless there's a suicide note, or documented history of depression, it may be impossible to establish a drug overdose as a suicide.
In the end, Oquendo said, many overdose deaths are classified as "undetermined."
One suicide expert explained why.
"If you're a coroner, it's not easy to discern intent," explained Jerry Reed, executive committee member of the National Action Alliance for Suicide Prevention, in Washington, D.C.
However, he said, it's known that both suicides and opioid overdose deaths have been rising.
According to the U.S. Centers for Disease Control and Prevention, the national suicide rate rose by 24 percent between 1999 and 2014 -- from 10.5 deaths per 100,000 people, to 13 per 100,000.
Meanwhile, the opioid toll keeps growing. Recent research has found a leveling off in Americans' abuse of prescription opioid painkillers -- like Vicodin, OxyContin and codeine. But abuse of illegal opioids, like heroin, is also rising.
And overall, opioid overdose deaths are still climbing.
Last year, a U.S government study highlighted the impact that heroin alone is having: Between 2002 and 2016, deaths from the drug soared by 533 percent nationwide -- from just under 2,100 deaths to more than 13,200.
How many deaths might be suicides? No one knows, Oquendo said.
But some research suggests opioids are behind a growing number of suicides, at least based on deaths that are officially classified as such. One study found that the proportion of U.S. suicides that were attributed to opioid overdose rose from 2.2 percent in 1999 to 4.3 percent in 2014.
It's vital to understand how often people with opioid abuse problems are suicidal, Oquendo said.
"The interventions for those people would be much different," she explained.
The best treatment for opioid addiction involves medication -- such as buprenorphine or naltrexone -- that blocks the effects of opioids. But, Oquendo said, people who are suicidal need other types of help, such as treatment for underlying depression.
Reed agreed. "If you treat it only as an opioid problem, you won't address the underlying issues."
But in general, Reed said, "these people don't want to be addicts. They want to alleviate pain, whether it's physical or psychological."
Similarly, he said, people who are suicidal do not want to die, but want to end their pain.
As it stands, Oquendo said, doctors do not routinely screen for suicide risk in scenarios where they might spot people who are vulnerable to an intentional opioid overdose.
That screening, she said, could happen in emergency rooms, when people are brought in for an opioid overdose -- or when people start medication treatment for opioid abuse.
But, Oquendo added, screening should ideally be broader than that. For example, she said, doctors could screen for suicide risk when they are prescribing opioids to a patient -- especially for chronic pain.
However, access to specialized care is a major obstacle, both Oquendo and Reed said.
In areas where the opioid epidemic is most acute -- including rural areas -- people may not be able to find a doctor who can prescribe opioid-abuse medications, let alone a mental health professional.
"The lack of access to interventions that work is lethal," Reed said. "We need to figure out how to make these interventions more readily available."
For now, he has some advice for families of people with opioid abuse problems: If they land in an ER with an overdose, make sure they have a full evaluation there, including screening for suicide risk.
More generally, Reed said, "try to stand by them. They need connection, support and love from the people around them."
He also recommended that people in crisis call the National Suicide Prevention Lifeline, at 1-800-273-TALK.
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SOURCES: Maria Oquendo, M.D., Ph.D., professor, psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia; Jerry Reed, Ph.D., executive committee member, National Action Alliance for Suicide Prevention, Washington, D.C., and senior vice president, practice leadership, Education Development Center, Waltham, Mass.; April 26, 2018, New England Journal of Medicine